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Rethinking primary care’s gatekeeper role

Gatekeeping is the term used to describe the role of primary care physicians or general practitioners (GPs) in authorising access to specialist services and and diagnostic tests. Gatekeeping has important influences on service utilisation, health outcomes, healthcare costs, and patient satisfaction. In an article published in the British Medical Journal, we discuss the role of gatekeeping in modern health systems.

In the UK access to NHS and private specialists is generally possible only after a referral from a GP. Gatekeeping was developed as a response to a shortage of specialists and a desire to control healthcare spending and has been an accepted practice in the UK for many years. The NHS is under considerable pressure to use its resources efficiently, and GPs have helped the NHS to achieve this goal through managing a large proportion of NHS workload in primary care. However, GPs in the UK now find themselves under considerable workload pressures. In an 11-country survey of primary care physicians, it was GPs in the UK who had the shortest consultation lengths and were the most stressed. Could direct access to some NHS services help reduce GP workload and facilitate greater patient choice?

Internationally, there is a large variation in the role of primary care physicians in “gatekeeping”. In many countries, patients can access specialist services directly without a referral from a primary care physician (sometimes with a co-payment). Although it is often assumed that gatekeeping will help control healthcare costs, there is little association between the strength of gatekeeping in countries and the proportion of GDP spent on healthcare. Some countries with weak gatekeeping spend a relatively small proportion of GDP on healthcare (e.g. Singapore).

Within countries, there can also be differences in gatekeeping policies. In England, for example, there are large variations between clinical commissioning groups (CCGs) in policies for giving patients direct access to services. For example, some CCGs allow patients to have direct access to physiotherapy services.

In the article, we look at the pros and cons of gatekeeping, describe gatekeeping policies in various countries, and highlight the need for more evidence to devise policy. We conclude that gatekeeping policies should be revisited to accommodate the government’s aim to modernise the NHS in terms of giving patients more choice and facilitate more collaborative work between GPs and specialists. At the same time, any relaxation of gatekeeping should be carefully evaluated to ensure the clinical and non-clinical benefits outweigh the costs.